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clinical-case-summary

clinical-case-summary

Write a structured clinical case summary or case presentation. Use when asked to write a clinical case summary, case presentation, patient case report, or clinical handover. Produces a structured summary using SBAR or SOAP format. For educational and documentation purposes only — not a substitute for clinical judgement.

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name: clinical-case-summary description: "Write a structured clinical case summary or case presentation. Use when asked to write a clinical case summary, case presentation, patient case report, or clinical handover. Produces a structured summary using SBAR or SOAP format. For educational and documentation purposes only — not a substitute for clinical judgement."

Clinical Case Summary Skill

Produces structured clinical case summaries for educational, documentation, and handover purposes.

WARNING: For documentation and educational purposes only. All clinical content must be reviewed by a qualified healthcare professional. This is not clinical advice.

Required Inputs

  • Purpose (case presentation / handover / case report / educational / MDT summary)
  • Patient details (anonymised — age, sex, relevant background)
  • Presenting complaint and history
  • Examination findings
  • Investigations and results
  • Diagnosis or differential diagnoses
  • Management and treatment
  • Outcome (if known)
  • Format preference (SBAR / SOAP / Standard clinical / Narrative)

Format A: SBAR (Handover / Referral)

S — Situation [Patient identifier anonymised, location, reason for contact in one sentence]

B — Background

  • Age / sex / relevant past medical history
  • Current admission details
  • Relevant medications and allergies
  • Brief relevant social history

A — Assessment

  • Current clinical status
  • Vital signs if relevant
  • Key examination findings
  • Working diagnosis or differential
  • Recent investigations and results

R — Recommendation

  • What you need from the recipient
  • Urgency level
  • Immediate actions already taken
  • Questions or concerns

Format B: SOAP Note

S — Subjective [Presenting complaint in patient words. Symptom history: onset, duration, character, severity, associated symptoms, relieving/aggravating factors]

O — Objective

  • Vital signs: [BP, HR, RR, Temp, O2 sats]
  • Examination: [Systematic findings]
  • Investigations: [Results with reference ranges]

A — Assessment

  • Primary diagnosis: [With brief rationale]
  • Differential diagnoses: [Ranked with reasoning]

P — Plan

  • Immediate management
  • Investigations ordered
  • Treatments initiated with dose, route, frequency
  • Referrals
  • Safety netting: what to watch for, when to escalate
  • Follow-up plan

Quality Checks

  • Patient details fully anonymised
  • Allergies and medications included in handover formats
  • Safety netting included in SOAP plan
  • Disclaimer included

Anti-Patterns

  • Do not include any identifiable patient information — full names, dates of birth, NHS or MRN numbers, or specific addresses must be anonymised or replaced with generic identifiers
  • Do not omit the clinical disclaimer — this output is for documentation and educational purposes only and must not be presented as clinical advice
  • Do not confuse the SBAR Recommendation with a treatment plan — R is what you need from the recipient, not a full management plan
  • Do not list differential diagnoses without noting the reasoning for ranking — an unranked list of differentials is not clinically useful

Example Trigger Phrases

  • "Write a clinical handover using SBAR for this patient"
  • "Summarise this case in SOAP format"
  • "Write a case report for [clinical scenario]"
  • "Prepare an MDT summary for this patient"
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